Barnett, Vivian OF QUEE950U-q�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director
ly 4t�A— Case;; x"2-
Cremation
T =�:e Cremation Started 1
Cremation Completed
e o f C o n t a i n e r Cf0?7Q
arks
� p_
PINE VIEW CEMETERY AND CREMATORIUM
RECEIPT FOR BODY PURSUANT TO NEW YORK STATE PUBLIC
HEALTH LAW SECTION 4145(2)(B)
1. NAME OF DECEASED AS IT APPEARS ON THE BURIAL-TRANSIT PERMIT
114�
2. DATE THE BODY WAS DELIVERED
3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
/�!I� jla, �2 e,49 83- S-��
4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
5. NAME OF PERSON IN CHARGE OF CEMETERY
4�w tvv�-
6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER
7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
o,� Z...-
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
&A -L,2"` G R V<r l\I 4 -
9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
�Q�
SULLIVAN-MMAHAN&POTTER FUNERAL BOMB
4077 Bay Road
Qwmdxiry,NY 12804
(518)M 2067
"Customer's Designation of Intentions"
y Z
Name of Deceased:
Cremation: /2- ./,z z/G 3 �
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at CXReturn to Family
❑ Entombment at ❑ Other (specify :
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
(Signature)
(Printed Name) (Relationship to Deceased)
(Address)
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Signatu of Funeral Director Date ^�
or Undertaker or undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory) ,
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSMMN Rev.9✓96
TOWN 01: OUEENSUURY �� _
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbuiy. New Yolk 12004
Phone (518) CrennaloHum 7,15-4477 (if no answer)
Ceinelery 745-4476
AUTHORIZATION I O C HEMAI E
I-he undersigned requests and aullmizes Pille View ClUIIIatullUlll. in accuidance with and subject
to its Rules and Regulations to cremate the ieniains ul:
- L',vv-gin
(NAME) (SEA)
tr s `rJ l� {G'44
(STREET) (CITY) (STA- 1=) (ZIP CODE)
who died on /ri` day of Zp�
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or nanne of person authorizing cremation:
od. AV
Relationship to deceased
Q
Name of Funeral Home f� '
IMPORTANT
I represent that to the best of my knowledge, (lie deceased has or ias no acemaker In his or her
body. (CIRCLE ONE)
1 certify that I have the full power and authorization to arrartye for the cremation of the remains and
to direct the disposition of the cremated remains, that any personal possessions have either been
removed or may be destroyed, and agree to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss or damages which may be made
against them by reason of or connected with the cremation of said remains as directed,whether
suc ims or deman are or are not wholly groundless, false or fraudulent.
(WIT ES ) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 10�- /adlp z'
yp
-fL 9